Category: public health

How to avoid hitting people with your car doors

A cyclist was taken to hospital in Victoria this afternoon after colliding with a van door. The woman in her 20s was heading west on Pandora Avenue just past Vancouver Street about 1:15 p.m. when the driver of a white van parked on the side of the road opened his door

Times Colonist – 12-August-2014

Dear most of us who drive cars, and therefore have to open doors to get out of them, here are two things we can do to avoid hitting cyclists (and other people) with our car doors.

Separated bike laneChange the system! Advocate for separated bike lanes in your city/town, especially on major roads. The current setup of curb – parked car – cyclist – moving car means the cyclist has to choose between getting swiped by moving traffic, or risk “colliding with a van door”. The City of Victoria is planning a separated bike lane for this very street. Imagine how hard driving would be if there were people walking along the road with you, and not in a separated walk lane (also known as a sidewalk). This process of building better facilities for cycling will take a few years, but it’s worth it for everyone. Cyclists are safer, pedestrians are safer because cyclists are less likely to use the sidewalk. Car drivers are safer on major roads because they will have fewer people in their way, what with all the cyclists using their fancy separated lanes, and all the car drivers looking at all those fancy cyclists saying “Hey, I can do that too!”. Tell your city to start building separated cycle tracks now.

Door Lane

Open the door with your right hand! Try this next time you park a car and exit. Open the car door with your right hand. As your right hand swings across your body to get the door handle, notice that you’re now facing left automatically, it’s magic. You’re no longer opening the door with your left hand while looking right to pick up your cellphone or your bag. This simple hack ensures that you always check that it’s safe to open a door, and that there are no humans (or large animals) in the door lane before you open the door. I could tell you to always check before opening the door, whichever hand you use, but who am I kidding. We have limited attention spans and we’ll forget to look that one time there’s a human in the way.

Door picture courtesy Gary Kavanagh used under a creative commons license. Picture of bike lane is from the City of Victoria pdf I linked to.

School Meals and Child Death in India


Like most, I am appalled and saddened by the death of 20+ (and rising) children in Bihar, poisoned by pesticide in their state-provided school lunch. This guardian article has a good run down on the issues that beset the program.

The fear is that attention is being diverted from what is an acute problem in many of India’s state-run or state-assisted schools. While the ruling party in the state looks for excuses, the harsh reality is that food provided to children all over the country is often substandard, and sometimes not even fit for human consumption.

Indias deadly problem with school meals | Kishwar Desai | Comment is free |

What is missing from the analysis is the magnitude of the hunger problem India is trying to solve. It is estimated that over 40% of children are undernourished in IndiaSchool meals have large public health benefits if done right. So it is vitally important that this program work, as this Indian teacher so eloquently details in her blog post.

It’s this absence of monitoring, I believe, that’s sabotaging a scheme that’s helped bring millions of children into school. The scheme was originally envisaged as government-run, but community aided and supervised. In practice, because parents and teachers are both busy, the whole system lacks anyone to ensure hygiene and quality.

The entire post is worth a read.

India reduced its global hunger index by about 24% since 1990. But note that Bangladesh’s percent reductions have been higher. As The Week points out, the last thing you want is for parents to pull their kids out of school because their kids will get poisoned, and for this program to end because it cannot be implemented without poisoning the kids.

What is especially egregious in this case was that the children noticed something was amiss, and alerted authorities, who did not listen. India’s authoritarian school institutions do not abide any feedback from children, especially the children of low/no privilege that attend government schools. Hunger and lack of choice probably played a part as well. There’s also early evidence that the school administrator ignored warnings from the cook about the cooking oil, calling it “home made”.

In the end, like everything else in India, it comes down to institutional quality and money. For all the complaints about excessive “regulation”, programs like Food Safe in BC are designed to ensure that people working with food know how to handle food, what to avoid, and how to identify and prevent dangerous situations. It takes effective institutions to ensure that quality and safety are maintained consistently and the people involved do the right thing most of the time. India’s performance in providing reliable services for its poor is also complicated by vast state-to-state disparities in institutional quality. India’s so called growth has also been top-heavy. People living in villages and the urban poor have not been a part of India Shining (or its new incarnation Bharat Nirman).

Can regulations on food safety, quality and delivery be enforced in the absence of a good monitoring and accountability system? Can India use the money it gets from “developing” to provide better services for its people? It will take time, and hopefully, eventually tragedies like the one above will be less frequent.

Alcohol Retail Privatization and Health

I had a conversation recently about alcohol retail store privatization where I mentioned that there is quite a bit of research linking privatization of previously public sector alcohol retail outlets and increased incidence of adverse events, especially in alcohol dependent people. Since I’ve forgotten who it was I had this conversation with, here are three studies on this issue, dear conversation partner:

From British Columbia, where a 2002 decision by a new BC Liberal government to greatly expand private liquor stores was studied. Here’s a link to the full study ($$) and the press release is below:

Excerpting from the study abstract:

Findings  The total number of liquor stores per 1000 residents was associated significantly and positively with population rates of alcohol-related death (P < 0.01). A conservative estimate is that rates of alcohol-related death increased by 3.25% for each 20% increase in private store density. The percentage of liquor stores in private ownership was also associated independently with local rates of alcohol-related death after controlling for overall liquor store density (P < 0.05). Alternative models confirmed significant relationships between changes in private store density and mortality over time.

Conclusions  The rapidly rising densities of private liquor stores in British Columbia from 2003 to 2008 was associated with a significant local-area increase in rates of alcohol-related death.

From Alberta: A study linking greater alcohol privatization with increased alcohol related suicides.

We examine the impact of privatization of retail sale of alcohol in Alberta, Canada, between 1985 and 1995 on mortality rates from suicide. Privatization took place in three stages: The opening of privately owned wine stores in 1985, the opening of privately owned cold beer stores and the selling of spirits and wine in hotels in the rural area in 1989–90, and finally privatization of all liquor stores in 1994. Interrupted time series analysis with Auto Regressive Integrated Moving Average (ARIMA) modeling was applied to male and female suicide rates to assess the impact of the three stages of privatization. The analyses demonstrated that most of the privatization events resulted in either temporary or permanent increases in suicide mortality rates. Other alcohol-related factors, including consumption levels and Alcoholics Anonymous (AA) membership rates, also affected suicide mortality rates. These analyses suggest that privatization in Alberta has acted to increase suicide mortality rates in that province.

Here’s a fairly comprehensive review of 17 studies, which was conducted by the American Centres for Disease Control (CDC).



A total of 17 studies assessed the impact of privatizing retail alcohol sales on the per capita alcohol consumption, a well-established proxy for excessive alcohol consumption; 9 of these studies also examined the effects of privatization on the per capita consumption of alcoholic beverages that were not privatized. One cohort study in Finland assessed the impact of privatizing the sales of medium-strength beer (MSB) on self-reported alcohol consumption. One study in Sweden assessed the impact of re-monopolizing the sale of MSB on alcohol-related harms. Across the 17 studies, there was a 44.4% median increase in the per capita sales of privatized beverages in locations that privatized retail alcohol sales (interquartile interval: 4.5% to 122.5%). During the same time period, sales of nonprivatized alcoholic beverages decreased by a median of 2.2% (interquartile interval: -6.6% to -0.1%). Privatizing the sale of MSB in Finland was associated with a mean increase in alcohol consumption of 1.7 liters of pure alcohol per person per year. Re-monopolization of the sale of MSB in Sweden was associated with a general reduction in alcohol-related harms.


According to Community Guide rules of evidence, there is strong evidence that privatization of retail alcohol sales leads to increases in excessive alcohol consumption.

This Mothers against Drunken Driving (MADD) document has a comprehensive bibliography, so does the Canadian Centre for Addiction and Mental Health.

I would characterize myself as part of the majority of people who believe their alcohol consumption is well under control, and as a consequence, does not mind the proliferation of liquor stores open till late, on Sundays, and running promotions. But as a public health issue, the huge costs of alcohol consumption are well known and extensively studied. It is surprising that jurisdictions rush headlong into liquor privatization when this kind of literature showing clear correlation (and good causal relations) between increased retail privatization and adverse outcomes for vulnerable populations is out there.


  1. Stockwell, Tim, Jinhui Zhao, Scott Macdonald, Kate Vallance, Paul Gruenewald, William Ponicki, Harold Holder, and Andrew Treno. “Impact on Alcohol-related Mortality of a Rapid Rise in the Density of Private Liquor Outlets in British Columbia: a Local Area Multi-level Analysis.” Addiction 106, no. 4 (2011): 768–776.
  2. Zalcman, Rosely Flam, and Robert E. Mann. “Effects of Privatization of Alcohol Sales in Alberta on Suicide Mortality Rates, The.” Contemporary Drug Problems 34 (2007): 589.
  3. Hahn, Robert A., Jennifer Cook Middleton, Randy Elder, Robert Brewer, Jonathan Fielding, Timothy S. Naimi, Traci L. Toomey, Sajal Chattopadhyay, Briana Lawrence, and Carla Alexia Campbell. “Effects of Alcohol Retail Privatization on Excessive Alcohol Consumption and Related Harms: A Community Guide Systematic Review.” American Journal of Preventive Medicine 42, no. 4 (April 2012): 418–427.
  4. Provincial Liquor Boards: Meeting the Best Interests of Canadians. Mothers Against Drunken Driving (MADD), 2012.
  5. Alcohol Retail Monopolies and Privatization of Retail Sales. Centre for Addiction  and Mental Health, 2010.
Wine image from public domain used under a creative commons licence.

Canada to stop asbestos mining and stop defending it.

Canada’s long and sorry saga of exporting death (asbestos) and defending it loudly and proudly in international fora is over and I needed to mark this happy day on the blog. The newly elected provincial government in Quebec, the Parti Quebecois have followed through on their campaign promise to finally end this small “industry” employing a few workers. Canada will no longer produce asbestos, or fight the listing of asbestos as a toxic substance.

It is going to take $50 million in government funds, a fraction of the cost of one fighter jet, to transition the workers away (if they get the money, not the mine owners). That’s it, why were we exporting death to India and other countries for this, I don’t know.

Canada’s many conservative and liberal governments fought hard for years to preserve the industry, using techniques lifted from tobacco propaganda, or today’s climate change challenges. I leave you with the ruling Canadian government’s response: Finely tuned to appeal to everyone who likes mesothelioma, cancer and death.

“Mrs. Marois’s decision to prohibit chrysotile mining in Quebec will have a negative impact on the future prosperity of the area,” (Industry Minister) Mr. Paradis said in a statement.

That about sums it up. But, it is a good day for public health, nevertheless.

Citing PQ pressure, Canada to cease defending asbestos mining – The Globe and Mail.

Featured image courtesy wikipedia used under a Creative Commons license (a micrograph of asbestos fibres causing lesions in the lung).

Indian firms push down global vaccine prices – Lessons for Canada

Cheaper vaccines from India are forcing global giants to slash prices. GSK announced its rotavirus vaccines at $2.50 per dose — or $5 to fully immunise a child — in response to a current tender administered by UNICEF.The offer is a 67% reduction in the current lowest available public price.

Hindustan Times

This is good news for many reasons. Preventable diseases kill over a million people every year, and one of the biggest factors in getting vaccinated is cost. India’s healthcare spending was estimated at US$ 40 billion in 2008, going up to 300+ billion in 2023. Forty billion is less than $40 per person, so saving 7-8 dollars on vaccinations alone for every one of the 26 million children born every year is a huge deal.

Development costs of vaccines and drugs are high and success is often uncertain. Pharmaceutical companies have used this to justify government enforced monopolies and per dose prices that are sometimes a 1000 times higher than the incremental cost of production. While this makes for good profits, it means severe lack of access in India, many African countries, and many excess deaths that could have been prevented. For years, India had what was called a process patent, not a product patent, which meant that if you could make a drug with a slightly different process, it would not get patent protection any more. How did this help India?

  1. Affordable drugs – Indian companies could make and sell drugs at a fraction of the cost without paying for drug development.
  2. Pharmaceutical Industry – This enabled the industry to grow and mature.

Of course, this also meant that India was considered an outlaw, and Indian pharmaceutical industry came under great pressure from the WTO to tighten patent laws, which it did. At the time, the concern (rightly) was that tightening patent restrictions would harm India’s pharmaceutical industry and reduce access to drugs. Has this come to pass? In some ways, yes. But the Indian pharmaceutical industry has also matured, and with government help, has been able to do its own development, clinical trials and production (which it was always good at). The focus on tropical diseases like rotavirus also means that US, European Companies, which have since moved away to treating chronic conditions like high cholesterol, erectile dysfunction, etc., have much more competition in the tropical diseases area and cannot charge premium prices to poor people any more.

So dear Canada, while you are negotiating with Europe about “free trade”, and trying to give European companies much greater patent protection for their drugs, know that this will very surely raise costs in the short term. Two important questions:

  1. Will Canada’s drug companies benefit?
  2. Will Canada’s consumers benefit?

Um, let’s take a look at Canada’s top 10 in 2009:


Rank Leading Companies Country Market Share (%)
1 Pfizer US 13.4
2 Apotex Canada 7
3 AstraZeneca UK 6.6
9 Merck US 6
4 Johnson & Johnson US 5.3
6 Novopharm (Teva) Israel 4.2
7 Novartis Switzerland 4
5 GlaxoSmithKline UK 4
8 Abbott US 3.9
10 Roche Switzerland 3.1
Source: IMS Health

There is one Canadian company in the top 10, and four European companies. Our pharmaceutical industry is not well positioned to be independent, or work to reduce Canadian drug prices, especially if laws strengthening patent protections for European companies come into effect. This will serve to weaken Apotex, and Canada does not have a big independent pharmaceutical company network born out of years of “isolation” to take advantage of any competition, or competitive advantages. So, while patent “reform” seems to not have hurt Indian industry as much as feared, it sure will hurt Canadian consumers.


Smoking ban for N.C. Bars and Restaurants

The bill approved Wednesday falls short of how it began: a total and sweeping ban on smoking in all public places. But the House's original bill left a wide loophole for bars, an exemption that worried restaurant owners who feared bars would steal late-night customers.

via House approves smoking ban for N.C. – Politics – News & Observer.

The bill (soon to become law) still contains the giant “private club” loophole I had mentioned earlier, so, 1.5 cheers. And strange exemption for cigar bars (where smoke is emitted), but not for hookah bars (where water filters quite a bit of the smoke).

Critically, as Laura Leslie pointed out, the law will allow local health officials to go above and beyond state law. So, a floor was established, not a ceiling, which is good. They were previously forbidden to enact any smoking bans. Now Chapel Hill/Carrboro can do what it has been wanting to do for years and finally kill smoking in all public places.

Circumcision and AIDS – Revisited


A post I wrote quite a while back on circumcision and AIDS remains my most commented post ever. In it (if you’re too lazy to click) I said that while research indicating a reduction in HIV infection in circumcised men was promising, there were a couple of concerns. One, that this could be a distraction from the single most effective prevention measure (no, not abstinence!), condom use. And two, that in certain cultures, especially among Hindus, this would be an absolute no no because circumcision is identified with being Muslim.

Anyway, in a review article, the Cochrane Centre in South Africa summarizes results from a meta analysis of a number of trials indicating a 50% reduction in HIV incidence among circumcised males. At this point in time, it is clear that circumcision is effective in reducing HIV incidence among heterosexual males. Based on this, the institute encourages the widespread use of circumcision as an AIDS prevention strategy.

So, am I still circumspect? Absolutely. I am still concerned that this research will be misinterpreted in a way that discourages condom use. In fact, the authors note that circumcised men indulged in more risky behaviour. Also, the incidence of HIV in the women these men were sleeping with increased from 9.6% to 13.8%, a 40% uptick. This increase was not statistically significant. No arguing with that, though the study was stopped early once it was clear that the men were helped, never mind the women, or reaching statistical significance in their case.

Given that it is very unclear what the effects of circumcision are on anything other than circumcised penises, which are only one half of the equation (or less!), I don’t think it is responsible to call for widespread use of circumcision as a public health strategy for the prevention of HIV until its effects on the other parties are known. While people are aware of this issue, I don’t think the science or the cultural landscape promote the use of circumcision as a HIV prevention strategy until its proven that women are not at risk from increased HIV incidence either biologically from a yet unknown mechanism, or socially from increased risk taking.

Men have more power in most societies to demand and receive sex on their terms. So the male centric nature of this research, and the conclusions drawn are disturbing. How irresponsible is it to encourage a public health strategy that appears to increase risk taking behaviour among men when the effects on the women are yet unknown, with only a statistically “insignificant” 40% increase in HIV incidence among women being observed?

I am. for very good reason, still circumspect on circumcision.

Whisky flavoured condoms courtesy bruno  girin’s photostream used under a creative commons license. Now how’s that for a turn on, whisky!

BC Bicycle Helmet Law – NC Connections

(b.1) that a person operating or riding as a passenger on a cycle on a path or way designated under paragraph (b.3) must properly wear a bicycle safety helmet

British Columbia Helmet Law

I got my bike on Thursday and finally, the vile flu that laid me low for a week has decided to sink slowly back into a tuberculotic cough. Blogging should get back to normal speed and topics as I unpack, start biking, and can live life again without being racked by chills and bad dreams.

Figured I should get back on my bike ASAP, but I decided to first check if BC had any bicycle helmet laws, because we’re like that, we have a lot of what would be considered “paternalistic” laws south of the border. And, it does, and guess what, the project evaluating the law was performed by UNC’s Highway Safety Research Center, small world, ai!

Apropos nothing, here’s the US list of states and their various bicycle/motorbike laws. Note that only 20 states (and DC) require the use of helmets for motorcyclists, quite insane. Fall on your bare head at 50 miles an hour and you are dead, vegetable, or both. In contrast, All of Canada is under universal motorbike helmet laws. Of course, no U.S state has bicycle helmet laws that cover adults. In contrast, four Canadian provinces have mandatory bicycle helmet laws.